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Falls and Fall Prevention in the Elderly: Insights from Jamaica
Kenneth James
Jacqueline Gouldbourne
Chloe Morris
Denise Eldemire-Shearer
Department of Community Health and Psychiatry
Mona Ageing and Wellness Centre
University of the West Indies
Mona, Jamaica
2
Abstract
Falls among the elderly is increasingly being recognized as an issue of concern in both developed and developing countries. Falls in the elderly may precipitate adverse physical, medical, psychological, social and economic consequences. In Jamaica, there are no exhaustive studies or literature that have fully captured the epidemiology, aetiology or impact of such falls, though there is evidence to suggest that it is an issue that warrants some attention. This paper, through the use of quantitative and qualitative methods sought to gain insights on the situation regarding falls among the elderly in Jamaica. Through literature reviews, canvassing of medicals records, conducting focus groups and interviews, perspectives were gleaned on falls among elderly persons in Jamaica. Contributory and risk factors, and perceptions and costs were explored, as were any existing fall prevention policies or policy thrusts. The emerging picture is that falls are not a rare occurrence among older persons in Jamaica and extrinsic factors such as poor road surfaces, poorly constructed steps and poor design of public transportation vehicles etc. are factors that cause falls in the local setting. Similarly, intrinsic factors related to co-morbid condition such as hypertension, diabetes and sensory impairment appear to also contribute to increased risk of falling. Further research on the issue is needed in Jamaica. So too are specific fall prevention policies and programs and actions to address prevailing concerns. Increased awareness of the occurrence of falls among the elderly and mobilization of efforts to decrease such events is needed, complemented by culturally relevant health education and promotion activities. Synergistic efforts of government, civil society, seniors and communities and households will be required for successful fall prevention. The time for planning and action is now.
3
Falls and Fall Prevention in the Elderly: Insights from Jamaica
Introduction
A fall can be defined as “unintentionally coming to rest on the ground or other lower
level with or without loss of consciousness”. [1] Falls among the elderly remain an ever-
increasing problem. Age-related changes and disease both have an impact on an older
person’s ability to balance. Similarly, cognitive impairment, various medications, and
changes in a person’s environment all appear to contribute to increased risk of falling. [2]
Falls in the elderly are a public health and community problem with adverse physical,
medical, psychological, social and economic consequences. These include disability and
deformity, fear of repeated falls, curtailment of routine social activities, direct costs of
medical care associated with injuries and loss of potential income.
Current literature suggests that the problem is of concern in both the developed and the
developing world. In Australia it is estimated that about a third of the elderly living in the
community experience at least one fall annually. [2] Gillespie citing studies from the
USA corroboratively asserts that that more than 30% of people aged 65 or older living in
the community fall each year, and that the risk of falling increases with age. [3] Statistics
from Ontario, Canada indicate that one-third to one-half of persons over 65 are prone to
falling, with falls being more common in older females. [4]
4
From the developing world, data are now emerging that suggest falls among the elderly is
a growing problem and of significant public health concern. Falls in the elderly in China
has been described as a very common complication in social life. [5] Based on a
prospective cohort study in Hong Kong among older adults, the prevalence and incidence
of falls were determined to be 19.3% per year and 270 per 1000 person-years
respectively; with recurrent falls happening in 4.75% of Chinese older adults every year.
[6] In Africa, one population-based survey from Tanzania that examined the injury
morbidity in an urban and a rural setting indicated that among persons over sixty years
old, falls accounted for about 35% of reported injuries in both settings. [7] In Latin
America and the Caribbean, analysis of data from the SABE (Salud, Bienestar y
Envejecimiento en América Latina y el Caribe) study on Aging, Health, and Well-being
conducted in seven cities across the region, reported the prevalence of falls as varying
from 21.6% in Bridgetown (Barbados) and 29% in Havana (Cuba) to 33% in Mexico
City (Mexico) and 34% in Santiago (Chile). [8]
The number of elderly is increasing most rapidly in Asia, Latin America, the Middle
East, and Africa. Developing countries will continue to experience rapid population
aging in the coming decades and by 2025, there will be 839 million older people living in
developing countries, 500 million more than will be living in developed countries. [9]
Melton [10] has predicted that the aforementioned regions will account for over 70% of
the 6.26 million hip fractures expected in the year 2050. Moreover, about 90 percent of
hip fractures are associated with a fall, with the vast majority of such falls being from a
5
standing height or less. [11]. Consequently, there is increasing imperative to address falls
and fall prevention among the elderly in developing countries such as Jamaica.
Background and Rationale
The Caribbean has been identified as the most rapidly ageing region of the world.
Between 1960 and 1995, there was a 76.8% increase in the elderly population. [12]
Among its regional island states, the average growth rate in the elderly population was
approximately 5.3% for the 1995-2000 period. The elderly as a percentage of total
population was 4.3% in 1950 and is estimated to reach about 15% by 2020. [13] In
Jamaica, a similar pattern has been observed with a clear and rapidly rising trend in the
elderly as a proportion of the population (See Figure 1).
Figure 1.
Constructed using data from http://www.un.org/esa/socdev/ageing/workshops/vn/jamaica.pdf
Elderly (60 years and over) as a percentage
of total population with time, Jamaica
5.0%
10.0%
15.0%
20.0%
25.0%
30.0%
1850 1900 1950 2000 2050
Year
6
By 2025 as much as 1 in 7 persons will be elderly. Moreover, characterizing this pattern
of increasing elderly is the differential growth rates within the various sub-age groups
over age 60, with the 75 years and above age group expected to double moving from
2.8% currently to 4.0 % in 2025.
Concomitant with the increase in elderly as a percentage of the population has been the
epidemiological transition where the leading causes of morbidity and mortality are no
longer infectious in nature but reflect the rise and predominance of chronic diseases such
as hypertension, diabetes and osteoarthritis. These conditions, are commonly known to
increase risk of falling, providing further rationale for the assessment of, as feasible, the
situation regarding falls and fall prevention in the elderly in Jamaica.
Aims and Objectives
This paper will focus on the situation regarding falls and fall prevention in Jamaica. Its
primary objectives are to describe and review as far as current documentation allows:
(1) the epidemiology of falls;
(2) health service impacts and costs;
(3) interventions and policies regarding fall prevention; and
(4) to elucidate and illustrate the situation regarding falls and fall prevention in
Jamaica through qualitative insights based on a number of case histories and
observations.
7
Methodology
Anecdotal evidence suggests that falls in the elderly is prevalent. The extent to which the
literature from Jamaica provides supporting empirical evidence is not fully known and is
perhaps sparse. Consequently a collective decision was taken by the research team to
employ a number of methods and strategies to provide evidence and insights regarding
falls among the elderly in Jamaica. These included a search and review of existing
literature, docket and patient information reviews, focus groups, interview with an expert
and case histories. To this end, tools were designed to elicit information from focus
groups, individual clients and patient records. The tools are attached at appendix 1-3.
Search Methodology
A comprehensive literature search was done. Scrutiny of articles from Caribbean and
Latin American publications was conducted to ensure the inclusion of as many relevant
published and unpublished studies and records that are pertinent to falls in the elderly.
Searches on multiple electronic databases were done. These included Medline, MedCarib
and PubMed. Internet searches, as well as manual checks of reference sections of review
articles and studies published in the last ten years, including review of the published
articles in the West Indian Medical Journal and the Post Graduate Medical Journal of the
Caribbean.
Document Selection
Documents were screened to ensure appropriateness for inclusion in this study. The steps
followed appear below.
8
Step 1: Identification of relevant documents
Documents were identified from the electronic data base that could potentially be used in
the review. Duplicate studies were removed as well as studies unrelated to falls in the
elderly (e.g., documents that referred to “fall” as a season or falls in children). To further
ensure coverage of the topic documents related to trauma and fractures were also
included to deduce how many of these are resulting from falls.
Step 2: Screening Based on Initial Inclusion/Exclusion Criteria
Studies located in Step 1 were screened based on inclusion/exclusion criteria, as outlined
in the table below. All documents retrieved in Step 1 were screened based on title and
abstract. Documents were omitted from the next level of screening if they failed to meet
all of the inclusion criteria, or met at least one of the exclusion criteria (see Table 1).
Table 1: Inclusion/Exclusion Screening Criteria
Inclusion Criteria Exclusion Criteria
1. Topic: Related to fall or fall injury
2. Age Group: Seniors (majority of
participants 60 years or older)
3. Languages English
4. Settings: Caribbean and Latin
American based.
1. Studies that target children or youth
2. Studies predominantly based on records
of persons under 60 years of age.
3. Records of trauma unrelated to falls.
4. Studies based in other geographic
regions.
9
All records and documents that met the relevance criteria were retained for the data
extraction phase of the review process.
Review of patient/client records
To obtain clinic-based data regarding falls among the elderly. The records from a typical
community health centre/ primary care clinic were reviewed. The dockets and the
summary diagnoses registers of patients attending the Social and Preventive Medicine
(Hermitage/August Town) clinic between January 2004 and September 2006 were
eligible for study. The clinic serves a catchment area with a population of 35,920 persons
with the majority of communities falling in the low- to middle-income categories. The
dockets and records for the period covered some fifteen thousand, four hundred and fifty
(15,450) person-visits. From these, dockets of patients 60 years and over were selected
and reviewed to ascertain whether the visits were in any way fall related. Additionally,
from the summary daily register which records visits and diagnoses and which uses both
ICD-9 and ICD-10 coding, all diagnoses related to trauma, dizziness/vertigo,
hypertension, diabetes, cardiac disease, cerebrovascular disorders, epilepsy and arthritis
were also selected for examination and the dockets reviewed for any history of falls
during the period studied. This approach was necessary since falls are not necessarily
recorded as a diagnosis but may be included in the medical history as a presenting
complaint associated with these primary diagnoses.
All relevant records were retained for the data extraction phase of the review process.
The Data Extraction Form (Appendix 1) was developed based on the researchers'
knowledge of falls. The data extracted included information on medical history; date,
10
time and circumstances of the fall; type of injury resulting from fall; consequences and
outcomes resulting from the fall, and where possible economic costs associated with the
fall.
For quality control, two reviewers extracted the information for each document and
compared results. Any differences were resolved through discussion. The data extracted
were entered into a spreadsheet, analyzed and summarized with help of the software
package, Statistical Package for the Social Sciences (SPSS version 12.0).
The research team also sought to complement its work by an interview with an expert
physiotherapist who saw patients reporting for treatment and physiotherapy services
secondary to falls. By reference to fall-related physiotherapy visits during the preceding
1 year period, the expert provided further opinions, insights and data, based on
experience at the University Hospital of the West Indies, the leading tertiary care and
medical teaching institution in the island. This activity essentially provided a perspective
on falls in the elderly based on hospital outpatient derived data.
Focus Groups and in-depth Case interviews
To augment the quantitative data obtained from the literature review and the review of
records, focus groups and case interviews were done. The focus groups sought to obtain
information, opinions and perceptions regarding: characteristics of fall, intervention
approaches, risk factors, outcomes of falls and prevention implications. The participants
for the focus were recruited through the National Council for Senior Citizens which
liaises with and works extensively with persons 60 years and over throughout the island;
11
and which also networks closely with government, non-governmental organizations and
civil society on matters related to the elderly.
Four focus groups were held. The participants were selected so as to gain broad
representation from the varying backgrounds spanning the socio-economic gamut found
in the island. The focus group discussions were recorded, transcribed and the text read to
familiarize the researchers with the content. Content analysis then ensued by
identification of common themes and ideas expressed. These were then summarized and
are reported in the results section of this paper.
In addition to the focus group, three in-depth interviews of persons who fell within the
past year were done. This was done to further elucidate the situation regarding falls as in
many cases, medical records were curt and without details about the fall itself. These case
histories/in-depth interviews provided windows to the confluence factors that result in a
fall, helping to illustrate ‘the pathway to falls’ and the contexts in which they occur.
In an attempt to address the issue of fall prevention policies and interventions, the
research team enquired about any existing relevant national level documents. A review of
the National Policy for Senior Citizens as well as the National Policy for Disabled
Persons was conducted. In the absence of specific national policy directly concerned with
falls and fall prevention among the elderly, these were deemed to be policy documents
that might be relevant.
12
Results
From the literature search, two seminal papers pertinent to falls in the elderly in Jamaica,
were identified. These were Patterns of trauma injuries in rural versus urban Jamaica
[14] and Falls: A modifiable risk factor for the occurrence of hip fractures in the elderly.
[15] The former study was conducted between March 1, 1998 and April 30, 1998 at the
University Hospital of the West Indies (urban area) and at the St. Ann’s Bay Hospital
(rural area), among 974 patients and 458 persons admitted to the surgical services of
these hospitals respectively. At these institutions respectively, 22% (185) and 19 % (101)
of admissions were due to trauma, with elderly persons (60 years old or greater
accounting for 10.5% of such admissions. Additionally, data from that study indicate that
falls was the second leading cause of unintentional injury accounting overall for 31.5% of
unintentional injuries seen (26% at UHWI and 41 % at The St. Ann’s Bay Hospital) .
While the exact numbers and proportions attributable to falls were not disaggregated by
age group in the data reported, the authors [14] highlighted the fact that “falls were
confined to two groups, the elderly who usually fall at home in urban as well as
rural areas, and young children who fall from trees in rural areas”. In recognition of the
problem among the elderly, a public campaign to emphasize measures to provide a safer
home environment and minimize the injuries sustained from falls was recommended.
Williams-Johnson, Wilks, and McDonald further illuminate the situation regarding falls
among the elderly in Jamaica. [15] In examining the trauma registry records of the 152
hip fracture patients presenting at the University Hospital of the West Indies in Jamaica,
between January 1, 1998 and December 31, 2001, they showed that in 90% (137) of
13
patients diagnosed with hip fractures, the precipitating factor was a fall. More strikingly,
the overwhelming majority of these persons were aged 65 years-old and greater. The data
on the distribution of falls by age group is displayed in the pie chart below (Figure 2).
Figure 2:
Constructed using data from Williams-Johnson JA, Wilks RJ, McDonald AH. West Indian Med J. 2004 Sep;53(4):238-41.
With regard to the place of occurrence of falls resulting in hip fractures, for elderly
persons 65 years-old and over, the home was the predominant location of the fall,
implicated in over 80 % of cases. Figure 3 shows the distribution of falls by place of
occurrence for the patients presenting with hip fractures.
Age distribution of persons presenting with hip fractures subsequent
to falls at the University Hospital of the West Indies,
Jamaica (1998-2001)
9%
91%
Age ≤ 64 years
Age≥ 65 years
14
Figure 3:
Constructed using data from Williams-Johnson JA, Wilks RJ, McDonald AH. West Indian Med J. 2004 Sep;53(4):238-41.
Interestingly “places of abode or residence” (i.e. home or nursing home) where it is likely
that the majority of time in a typical day may be passed were specifically identified as the
site of the fall (87.6% of cases). Among the elderly, further examination of factors within
the home environment as well as personal medico-physical factors is warranted if the
occurrence of falls among these persons is to be reduced.
In trying to capture the typology and aetiology of falls among older persons, various
rubrics have emerged such as “accidental” and “non-accidental” causes. Increasingly
studies [1, 16, 17] now classify the factors associated with falls/causes of falls as
81.8%
3.3% 5.8%1.7%
7.4%
0.0%
20.0%
40.0%
60.0%
80.0%
100.0%
Home Street Nursing
Home
Public
Place
Other
Distribution of falls by location among persons presenting
with hip fractures subsequent to falls at the University
Hospital of the West Indies, Jamaica (1998-2001)
15
“extrinsic” and “intrinsic”. Extrinsic factors or causes refer largely to environmental
phenomena (e.g. rugs, floor surfaces, pathway obstacles, potholes). Intrinsic factors or
causes on the other hand relate to age-associated physiological changes, disease or
medications. Within the Jamaican environment, combinations of extrinsic and intrinsic
factors contribute to the occurrence of falls.
In the analysis of extrinsic factors associated with hip fractures most of which were due
to falls and most of which occurred in elderly persons, the Jamaican data presented by
Williams–Johnson et al [15] yields the following. Of 137 patients who fell,
approximately 16% fell from a bed or a chair/stool, while about 8% tripped over objects
such as boards, garden hose, slippers, loose carpet, and electrical wires. In of about 58%
of cases, the location/activity associated with the fall was not stated. However, about 14%
were associated with slips in the bathroom.
With regard to intrinsic factors, conditions such as hypertension (37%), diabetes mellitus
(21.7%), chronic ischaemic heart disease (7.6%), dementia including Alzheimers disease
(7.6%) were the main illnesses noted among the patients who fell. Less commonly
reported were loss of vision in one eye, cataracts, and seizure disorders. [15] While no
cause-effect relationship could be authoritatively established from the study, the co-
existence of both intrinsic and extrinsic factors in the patients studied allude to the multi-
factorial causation of falls and to the dynamic interplay of environment, physiological
impairment, physical illnesses, and activities being pursued.
16
Review of Health Centre records: findings
Twenty-seven cases of falls were identified from the review of the records of 5412
person-visits by individuals 60 years and over to the health center during the 33-month
period, January 1, 2004 to September 30, 2006. Among these 27 persons the age range
was 61-82 years with a mean age of 71.3 years (s.d. = 6.1, median = 70 years). The age
distribution is shown in Figure 4 below.
Figure 4
.
By gender, 66.7% of the cases seen at the health centre were females; males comprising
the remaining 33.3%. This ratio is in keeping with the national observed pattern of
utilization of clinic health services where 66 % of users are females.
60 65 70 75 80
Age (yrs)
0%
10%
20%
30%
Percent
Age distribution of persons 60 years and overattending the Hermitage /August Town Clinic
for falls (Jan. 2004- Sept.2006)
17
Diagnoses, co-morbid illnesses and disability
Of the 27 files perused, 5 had a primary diagnosis of vertigo/dizziness of unknown cause,
two -fractures; one-epilepsy; and two had the diagnosis of “falling”. The remaining 17
(63%) were listed as various cases of trauma or injury to the body parts.
Co-morbid illnesses relating to the fall or attendant in the persons who fell are displayed
in Table 2 below. Diabetes and hypertension, hypertension and diabetes, hypertension
with heart disease were the most common mix of co- morbid diagnoses.
In fact, diabetes and hypertension were simultaneously present in 30.6 % of those elderly
who fell; and either diabetes or hypertension was a co-morbid condition in 67.6% of fall
cases presenting to the health centre studied. Overall, only in 14.8% of the fall cases
studied, were there no documented co-morbid conditions.
Table 2. Co-morbidity among elderly persons who presented at the
Hermitage/August Town health centre for falls
(Jan.2004-Sept.2006)
Illness
Frequency
Percent
Diabetes 1 3.7
Diabetes & Hypertension 5 18.5
Diabetes & Hypertension, heart disease
4 7.4
Diabetes & Hypertension & mental illness
1 3.7
Diabetes & Hypertension & another illness
1 3.7
Hypertension 5 18.5
Hypertension, heart disease 3 11.1
Hypertension, heart disease & mental illness
1 3.7
Heart disease 1 3.7
Other neuro-psychiatric conditions
1 3.7
No co-morbid condition recorded
4 14.8
Total 27 100.0
18
Regarding specific physical disabilities and impairments, impairment of sight was noted
in 11.1% of cases and a similar proportion had hearing impairment. Mobility problems
were documented for 22.2% of elderly persons who fell. No disability or other physical
impairment was reported for 51.9% of those elderly who fell.
Figure 5:
Injury to body parts
The lower limb was the most frequently injured area of the body during falls (injured in
52% of cases studied). There were two head injuries and one eye injury secondary to
falling. The bar chart below illustrates the relative frequency of the injuries by body part.
Figure 6
Physical disability/impairment among elderly persons
presenting to the Hermitage/ August Town Health Centre
(Jan.2004 - Sept.2006)
Sight, 11.1%
Hearing, 11.1%
Mobility, 22.2%
None, 51.9%
0%
5%
10%
15%
20%
25%
30%
35%
40%
Head Back Arm Knee Leg Chest Eye
Injury secondary to falling by body part(n=27)
19
Place where the fall occurred
The place where the fall occurred was not recorded in most cases (~78%). In the few
instances where this was recorded, places mentioned were the public bus, or in the
home/yard environment (over a dog, at the gate, climbing stairs and inclines)
Consequences (medical) of fall
The immediate impact and consequences from the falls seen in health centre were
laceration needing cleaning and dressing (85% of cases). These cases also complained of
pain from tissue damage. For some patients the wounds resulted in difficult to heal,
chronic leg ulcers requiring frequent cleaning and dressing at the health centre.
Insights from expert physiotherapist based on hospital outpatient data
Insights on elderly outpatients attending the physiotherapy department consequent to falls
were obtained through the collaborative interview of an expert physiotherapist. This
provided a window into characteristics of fall cases seen in a hospital ambulatory setting.
This data further complements the hospital derived data gleaned from the literature and
has the advantage of providing post-hospital discharge data where the consequences and
impact of falls are further illuminated.
For the twelve–month period October 2005 to September 2006, twenty-nine (29) cases
were identified from the outpatient physiotherapy department of the hospital. Nine (31%)
were male and 20 (69%) were female.
20
Their ages ranged from 62 years to 94 years; the mean age being 72 years (s.d. = 9.7). As
in the cases obtained from the health centre, the median age was also 70 years (inter-
quartile range: 63-76). Figure 7 below is a pictorial representation of the age distribution
of the cases seen at the outpatient physiotherapy department. The distribution reflected
some skewness to the right, suggesting the median as the preferred measure of central
tendency.
Figure 7: Age distribution of elderly patients seen at hospital outpatient physiotherapy department for falls (Oct:2005 –Sept 2006)
62 64 66 68 70 72 74 76 78 80 82 84 86 88 90 92 94
Age
0%
10%
20%
30%
Percent
21
Injury following fall
The majority of patients (79.3%) seen sustained a fracture. Fractures of the lower limb
were noted in 48.2% of the cases and fractures involving the upper limb occurred in
27.5% of the cases. In approximately one in six cases muscular pain and other damage
was the main cause of referral for physiotherapy. The distribution of injuries is shown
below in Figure 8.
Figure 8
Co- morbidity
Among those clients of interest seen for physiotherapy, diabetes mellitus and
hypertension predominate as co-morbid conditions. This pattern was similar to that
observed at the Hermitage August Town Community Clinic. Diabetes or hypertension
Distribution of injury sustained after a fall among elderly
attending outpatient physiotherapy department post-
hospitalization (Oct. 2005-Sep.2006)
0.0%
10.0%
20.0%
30.0%
40.0%
50.0%
Fracture: arm Fracture: leg Fracture; arm
and leg
Injury to back Muscular pain
and other
damage
22
was a co-morbid condition in 51.6% of cases. Notably however, there was an increased
prevalence of cancer (6.8%) among these elderly who fell and were seen for
physiotherapy in the hospital outpatient setting as compared to those seen at the health
center level. The finding is not surprising given the somewhat different and more severe
morbidity that would be expected among those who had been admitted to hospital
vis-à-vis clients obtained from a community clinic setting. Table 3 captures the
distribution of attendant co-morbid conditions.
Table 3: Prevalence of co-morbid conditions among elderly patients
experiencing falls seen at outpatient physiotherapy department (Oct. 2005 – Sept. 2006) [n=29]
Place of fall
Figure 9 displays the pattern of falls by place. The house was the most frequently
documented site of falling accounting for 52% of the location of fall for those persons for
whom site was recorded and at least 38% overall of the falls among the clients studied.
Co-morbid condition %
Diabetes 3.4
Diabetes & Hypertension 10.3
Diabetes, Hypertension & Heart Disease
6.9
Hypertension 20.7
Hypertension & Heart Disease
10.3
No co-morbid condition documented
31.0
Asthma 3.4
Cancers 6.8
Gastric ulcer 3.4
Scoliosis 3.4
Total 100.0
23
Twenty- eight percent (28%) cases said they fell outside within the yard or home
environs while only 3.4% of falls occurred at work. In 28% of cases the site of the fall
was not recorded.
Figure 9:
Distribution of place of fall among elderly patients experiencing
falls seen at outpatient physiotherapy department
(Oct. 2005 – Sept. 2006) [n=29]
House
38%
Outside: In
yard/home
environs
28%
Road
3%
At work
3%
Not stated
28%
Consequences (medical) of fall
The majority of persons, 66% (19), suffered marked immobility from the injury they
sustained when they fell. This immobility coexisted with severe pain. One person who
worked full time work was medically unfit to attend work for some days. All other
persons were retirees.
Persons who fell and sought attention at the hospital underwent a variety of medical
treatments and procedures. All cases had radiological investigations (X-rays) of the
24
injured areas. Sixty-two percent (18) of the cases had surgical operations done. In a
minority of instances (10.3%), CT scans or ultrasound investigations was required. All
cases subsequently attended orthopaedic and physiotherapy therapy clinics. The number
of visits made by the clients reviewed ranged from 1 to 24; the median number of visits
being 4 (inter-quartile range: 2.75 – 8).
Health impact and social/economic burden of falls
The impacts of falls among the elderly are manifest in a variety of ways. It is useful to
recognize that falls among the elderly not only incur directs cost clearly associated with
the falls, but also indirect costs and intangible costs. Direct costs include those associated
with the cost of medical care. Indirect costs include: the loss of income and productivity
associated with the fall, those of absenteeism from work, and losses from disability. It is
important to note that even though many elderly are retired persons, they continue to be
productive citizens contributing economically through self-employed activities,
agricultural endeavours, and their roles in many households as caregivers, and
grandparents. A fall of an elderly person can thus result in significant indirect costs.
Additional indirect costs include those of increased insurance premiums as well as those
of increased payments to beneficiaries when an insured person is injured. Intangible
costs occur due to pain and suffering or due to fear of falling again. This can disrupt the
normal routine and social activities of older persons. Falls among the elderly may
necessitate a disruption role changes that can negatively impact a family or household.
25
While the indirect and intangible costs are difficult to measure, preliminary insights into
the direct cost of falls can be gained by examination of the data presented below in Table
4. The data was obtained through information gleaned from patient records studied from
the community clinic (health centre) and those from the physiotherapy outpatient clinic
supplemented by case interviews with persons who had fallen and utilized these services.
Table 4: Minimum estimates of economic cost of falling in clients studied
Procedure
Minimum
costs
# of Health centre
cases utilizing
procedure or
service
Total
(Jamaican
dollars)®
# of Physiotherapy
cases
utilizing procedure
or service
Total
(Jamaican
dollars)®
X Ray
CT Scan
Ultra Sound
MRI
Surgery
Dressings
Health centre visits
Physiotherapy
Out Patient Clinic
Accident & Emergency
Pain Medication
Antibiotics
$1,500.00
$12,000.00
$4,000.00
$50,000.00
$20,000.00
$ 200.00
$ 100.00
$950..00^
$500.00
$500.00
$500.00
$1,000.00
15
27
27
27
27
22,500.00
5,400.00
2,700.00
13, 500.00
22,000.00
29
1
2
1
18
18
114*
7
29
29
23
43,500.00
12,000.00
8,000.00
50,000.00
360,000.00
3,600.00
108,300.00
3,500.00
14, 500 .00
14,500.00
23,000.00
Total $66,100 $626,400.00
^Represents the weighted average of a first visit of $2000 and 3 follow-up visits of $600 (recall typical number of visits = 4) * represents no. of person-visits for physiotherapy services ® N.B. To convert costs into US$, divide by 66. [$1US = 66 Jamaican dollars (J$)]
26
Table 4 highlights some major costs borne by patients as a result of the fall they
sustained. It is a rough estimate of the some of costs incurred. It is important to note that
room and board are not included and other incidentals that are inevitable with
hospitalization are not included (as these were not readily available). Health centre visits,
outpatient and orthopaedic clinic visits are calculated based on a minimum of one visit
only. As such these summary cost are minimum preliminary out of pocket expenditure
estimates and will under-estimate true costs. Additionally, a substantial portion of the true
costs is borne by government under its current cost-sharing schemes.
Based on the above figures with regard to falls, the mean minimum out of pocket
expenditure for those presenting to the community clinic was J$2,448 and that of those
seen by patients at the hospital outpatient physiotherapy clinic was J$21,600.
The average pension disbursed per month to beneficiaries of the government’s national
insurance scheme is about J$6,105.00 per month. Medical bills associated with a fall
thus may consume about 40% of pension for patients seen at the community clinic. For
those who utilized hospital services, payment of associated bills may constitute about
30% of annual pension. Among the elderly who may have other concurrent chronic
disease, fall exacerbate the economic burden of medical costs.
27
Focus Groups Results
Information was gleaned from four focus groups discussions; each with 8-10 persons.
Profile of the groups
The focus group participants were between the ages of 60 and 85 years. The groups
represented a mixture of persons from all socioeconomic and educational strata. Their
occupations included educators, health care professionals, casual labourers and sports
professionals. They were all retired but kept busy with volunteer work. Some were still
occasionally employed. On average, the gender mix was 65% female and 35% male.
The focus groups yielded information on places of fall, impact of fall and fall prevention
strategies. The results are as follows.
Experience with falls
In response to queries about experiencing a fall in the last few months, most persons
reported either falling themselves or knowing some older person who had fallen in the
last few months. This was for example expressed as “I fall down every time; they call me
‘Miss Fall Down’ ” and “I have friends who fall down very regular”. Some participants
noted physical injuries resulting from falls as exemplified by the statements ‘“I fell down
and broke my leg” and “Fell at home and hit my shoulder”
28
Causes of falls
On exploration of perceptions of causes of and contributory factors to falls, a myriad of
answers emerged. Theses included poor lighting on the street, holes and puddles in the
roads and sidewalks, uneven pavements, sidewalks cluttered with roadside vendors and
their ware and merchandise. Stumps remaining from incompletely removed road and
sidewalk signs were mentioned with angst as causing persons to trip, stumble and fall.
“Puddles and large pot holes in the roads, we have to jump to avoid the water and then
we fall down” and “Vendors on sidewalk as so we have to walk in the roads” are quotes
that illustrate the feelings of focus group participants.
Focus group participants also demonstrated an awareness of medical conditions
contributing to falls -“High blood pressure threw me down one time” and “Vertigo, our
head starts to spin and then we fall down”. Simultaneously, persons alluded to the ageing
process as having a role in precipitating a fall. “We just fall down, I guess that is what
happens when you get older; there are no reasons” quipped one participant. Another
noted. “I was going home. I have 18 steps and while going all of a sudden I notice I just
fall down going down all the steps…. I did not feel dizzy, not feel sick nothing. They said
the blood pressure was fine…. I cannot say what happened why I fell.” - suggesting that
falls may be of unknown medical cause.
The poor design of buses used for public transportation was mentioned as worrisome
issue. “There are not enough seats on the buses and so we fall down because we have to
stand and cannot hold on properly”. “The steps on the public buses are too high and
29
sometimes we fall trying to get into the bus”. Additionally, the rails on buses were
thought to be too high and persons had difficulty in holding on to these for support.
Other factors mentioned included violent attacks from robbers and problems of
adjustment to new glasses.
Fall prevention.
Focus group members had a plethora of suggestions to help prevent falls among older
persons. Improved lighting on the roads, improved road surfaces, and the use of rough-
cast cobblestones for sidewalks, were all proposed. There was expressed a need for
‘buses for seniors’ which would eliminate falls associated with the mad rush and chaos
while running after route taxis.
Some members had insightful comments advocating for maintaining a balanced diet and
exercising regularly, as well as, having regular medical checks to address vertigo. A few
persons expressed a resignation to fate, suggesting that little or nothing could done;
“Seniors will always fall”. In contrast, other persons felt something could be done.
Simple practical steps to prevent falls were mentioned such as moving obstacles/dangers
out of the way like fruit peels, plastic bags and other small objects, and wearing
appropriate footwear; as well as fixing leaking roofs that may ultimately lead to slippery
floors and falls.
30
The notion was expressed that little or nothing is being done by public authority to
prevent seniors or anybody from falling. A matrix presenting findings from the focus
groups is given as Appendix III.
Case Vignettes (distilled from in-depth interviews)
Case 1
A 60 year old female went to use the porcelain toilet bowl which had cracked some time earlier. She fell, with the bowl crashing under her weight. She had to be assisted by her husband and daughter. The porcelain chards caused severe laceration to her rectum and peri-anal area which bled profusely. She was rushed to the Accident and Emergency unit of the hospital where she was seen immediately. She received sutures, injection, and two sets of pills; one for pain and antibiotics. She was sent home and attended the community health centre for dressings. Her out-of-pocket expenses totaled $3000.00 Jamaican dollars ($45.45 US). She had no history of other pre-existing medical problems. In suggesting what persons can do to prevent falls, she said that, “people need to be careful when they are walking, especially when they are getting up in age, since you can get giddy, or get a cramp, or you eye get dark and pressure all those things can make you fall”. She also remarked that “Government working with the community could help provide a vehicle to take older persons who have difficulty to go to church and to the market on Saturdays or Sundays, thus reducing their risk of falling.
Case 2
A 65 year old female who indicated that falling was ‘a way of life for her’. She was diabetic and had arthritis. The first fall that she recalls was in 1999 and she has had three falls subsequently. When she fell the first time she was entering her half-finished house where she stumbled, fell on her face and hit her head on concrete block. She went to the doctor and was given pain medication. The doctor said she had injured her back. The second fall was near her gateway where she slid and fell “damaging the back even worse”. On that occasion she went to accident and emergency, where the back was x-rayed and she was give pain medication. Apart from her arthritis, she also, “ wondered if the sugar [diabetes] threw me down”. Four weeks ago, she fell again. As she lost her balance and fell backwards, she tried to ‘break the fall’, but she twisted her back and could not move then. “Now I walk and drag
31
my left foot, it feels very weak sometimes. I do exercise and it helps the foot, I think both the arthritis and the diabetes have something to do with the falls, and I am also foggy in my left eye”. When asked what are some of the things that cause falls, she said, “ Roads were not perfect, they were not smooth, water settles sometimes and persons have to make their way around the water. In making houses, sometimes the steps are too high, and the yard is not level; all these things can cause one to fall”
Case 3
A 72 year old man reported that he had fallen while climbing the steps to hang out some clothes three weeks ago. The wooden steps were wet and only one side had rails which was not strong enough to hold him as he started to fall. His daughter took him to the hospital accident and emergency. He was given medication for pain and had the back x-rayed. He reports from no chronic diseases, although his back had remained a problem since the fall. His suggestions to prevent falls is to level the surface of yards which are situated on gradients, and put in appropriate rails where necessary
The cases analyzed lead to development of the schema shown in Figure 10. The key
message emerging is that within the Jamaican context as elsewhere, falls represent the
confluence of increased physiological and environmental risks interacting with and
impacting on the performance of normal activities and tasks. Falls thus are more the
result of an accumulation of various probability risks rather than mere ‘passive
accidents’.
32
Figure 10: Falls - confluence of factors, risks and circumstances
•Diabetes •Arthritis •Age •Sight Impairment
•Gait and mobility disorders
•Medications
Performance of daily tasks and activities
•Lack of supportive hand rails •Uneven inclines and ground surfaces in yard
•Challenging stairs, very smooth floors
•Poorly designed steps •Puddles and holes in roads •Navigating half-finished houses and obstacles in home
•Weak or defective structures that must bear the body’s weight (e,g. toilet bowl)
Increased Physiological vulnerability
Increased Environmental risks
F A L L S
33
Fall prevention and intervention policies
The review of the National Policy for Senior Citizens as well as the National Policy for
Disabled Persons yielded the following.
There exists a series of policy statements, goals and strategies that are broadly outlined
National Policy for Senior Citizens. These broader policy statements while not
mentioning fall prevention, indirectly and encapsulate such initiatives through advocating
the following:
• That Older persons should be able to live in environments that are safe and adaptable to personal preferences and changing capacities
• That the keystone of all policy is to help older persons maintain the maximum degree of independent living.
• That national policy must be multisectoral in nature with input from ministries, government, NGO’s and the private sector - including housing and transport sectors.
• That the promotion of activities to safeguard the welfare of senior citizens should be an essential part of the national development plan.
• Attention to special groups particularly frail seniors, those in ill-health and the mentally incompetent are identified as needing special services (recall vulnerability to falls)
• Increasing the knowledge of all persons responsible for providing facts, information and advice to seniors citizens
• Health education and health promotion activities, for the prevention of disease and disability
• Training of community health workers in Health Care of Senior citizens especially on the early signs of impairment and disability in order to take timely action and establishing of a supply of technical aids including walkers, glasses, crutches and hearing aids.
• Making buildings accessible through provision of ramps and rails to staircases.
• Promotion, development and implementation of research activities to supplement current knowledge regarding the implications of ageing of the population and the needs of ageing populations; and the dissemination of information.
34
The majority of elderly persons are physically (88.5%) and mentally (85.9%) well. [18]
However, among those who have at least one disability, the elderly are disproportionately
represented. As early as 1991 the national census documented a total of 111,114 disabled
persons (50,966 male and 60,148 female). Notably, 56.77% of females who were
disabled were 60 years and over, while among males with disability, 46.78% were 60
years and over. [19] The National Policy for Persons with Disabilities advocates
prevention of disability through a variety of measures including:
• Environmental protection (which extends to the home)
• The early detection of disability and the timely intervention to minimize disabling conditions
• The provision of assistive aids/adaptive aids for persons with disabilities and the provision of the necessary concessions to for persons to acquire the same.
• Making public transportation physically accessible to persons with disabilities
The latter policies are congruent with those of the National Policy for Senior Citizens and
together synergistically foster an atmosphere conducive to the development and
implementation of fall prevention activities. The stage is thus set for specific actions
aimed at prevention of falls among older persons to be realized.
35
DISCUSSION
Limitations
Time constraints limited the number of searches and the types of analyses/research that
could be pursued. To arrive at a detailed analysis of the economic impact of falls would
require costing man-hours and productivity losses, medical interventions, and the social
consequences of falls. Time did not allow such detailed analyses but just crude estimates
of what some parameters might be were obtained.
The omission of falls as a primary or secondary diagnosis from patients’ records
presented a challenge. The searches of patients’ records pointed clearly to the fact that
many patients fell and presented to the medical facility, but fall was not recorded as a
diagnosis. It was only by extensively perusing the files that the occurrence of a fall was
made clear. This undoubtedly affected the ease with which cases could be identified
within the periods under study. Thus, eligible cases may have been missed. Additionally,
a fall could have occurred but not be necessarily recorded in some of the very cursory
medical notes. Moreover, present patients records are not stored electronically which
perhaps would have facilitated more comprehensive and efficient searches.
Although there exists, an awareness of falls among the elderly, few published documents
attempt to capture the issue of falls in the elderly as an issue of significant public health
concern in Jamaica. Hence, Jamaica-specific literature is quite limited and the relevant
papers available for review were sparse.
36
It must be acknowledged that most of the sources from which the quantitative data is
derived for this paper are not extracted from population-based or community-wide
household surveys. Rather, they emanate from clinic-based or hospital-based records. As
such, falls which occur without major consequences and falls which occur and are
“treated at home” will not be captured. Nevertheless, the information gleaned represents a
starting point; building blocks upon which data from more comprehensive studies in the
future may be stacked.
Our research indicates that falls in the elderly is an issue of significant concern. The
suggestion is that falls are a relatively frequent occurrence with resultant morbidity
ranging from soft injury through to fractures and possibly death. Hypertension, Diabetes
mellitus, cardiovascular disease, mobility disorders and sensory impairment were the
most prevalent co-morbid condition associated with falls and are known to be factors that
predispose to increased incidence of falls.
From both the quantitative and the qualitative analyses, it is strikingly evident that
environmental or extrinsic factors play a substantial role in the genesis of falls. Outside
the home, road conditions, public transport, the presence and state of sidewalks and
impediments such as pools of water and holes contribute to a large number of falls. This
argues for the elaboration of specific efforts to address and reduce these hazards. Such
efforts must be born of a combination of advocacy by seniors, civic groups and
researchers, and must also find fertile ground in the political and legislative arena.
37
On a practical level government and authorities need to be vigilant and must enforce the
regulations that address issues such as the illegal and improper use and cluttering of
sidewalks. Only then, will policy become meaningful through action. Only then, will the
true benefits of fall prevention activities be realized by the consumers including seniors.
Within the house and its immediate surroundings (yard), contributory falls range from
slippery floors, to uneven walking surfaces, to household clutter, to stairs without rails, to
poorly constructed steps, to defective weight-bearing furniture and fixtures. In the yard,
the uneven terrain, loose gravel and soil, haphazardly distributed objects as well open
drains and poor drainage increase the risk of falling. Consequently, awareness and
responsibility for fall prevention begins at the individual and household level. There are
relatively inexpensive steps which can be taken to reduce the risks of falling. These
include the use of rubber mats rather than the traditional slippery banana-bark varieties or
the attractive commercially manufactured straw mats that are known to be slippery.
Additionally, the use of rails and the maintenance of stools, chairs, rails and stairs can
decrease the likelihood of falls and their attendant morbid sequelae.
Health practitioners and caregivers need to be acutely aware of both ‘normal
physiological’ and ‘pathological’ changes with age. Distinguishing and discerning these
can preemptively alter risks of falls among elderly persons if appropriate actions are
taken and relevant information and advice are offered. Additionally, more astute
management of drug therapy for multiple co-morbid conditions can reduce the risk of
falling. Indeed, avoiding unnecessary polypharmacy and titration of medication doses to
38
fit clients’ changing needs, changing physiology and changing activities, can markedly
lessen the occurrence of iatrogenically-induced falls.
Education aimed at sensitizing persons, elderly and non-elderly, about falls and fall
prevention is a critical part of any fall reduction strategy. Health education and health
promotion strategies however must find resonance with the social and cultural milieu in
which it is carried out. As such, in Jamaica, the settings for such health
education/promotion activities should include the church, the Golden Age clubs, the
corners or yards where elderly men play dominoes, and the ‘home visit’ made by
Community Health Aides and other health professionals. In these settings, one is more
likely to find captive audiences and messages are more likely to be better received. The
media used is also to be tailored to the intended audience bearing in mind the special
challenges of low–literacy settings or the deficits (visual, auditory, or mildly impaired
cognition) that may exist. Schools are also not to be overlooked as children who learn
fall prevention in school can be the stimuli for change in families and communities. This
intergenerational exchange further enhances the relations between children and their
older relatives.
In promoting fall prevention activities, overcoming cultural practices and preferences
such as the practice of shining floors and steps until they achieve mirror-like properties
(“shine like a willy-penny”) may be challenging. However consistent messages and
recruiting key community leaders to support such efforts may be helpful. Additionally
there is need to change the cultural perceptions of “falls among the elderly as an
39
inevitable natural part of ageing”. The analysis of falls and how they occur indicates that
it is not, and that there are specific things that can be done to prevent them. Novel
approaches to change such attitudes may involve the use of role play and the discussion
of case scenarios.
Policies currently remain broad and overarching. The existence of general policies which
largely indirectly embrace fall prevention provides an avenue forward. However there is
need to develop definite and clear fall prevention policies and programs. These would
give focus to fall prevention activities and provide catalytic thrust to fall prevention
efforts. Additionally, specific leadership could be provided on the issue and fall
prevention more powerfully brought to the forefront of local and national activities.
Research provides the argument for advocacy and policy development. Programs also are
often rooted in formative research. The preliminary findings of this paper indicate the
need for greater evidence and holistic understanding of the epidemiology of falls, its
incidence and associated dynamics, its associated costs and impact on the individual,
family, community and state, and the best practices to reduce falls within the Jamaican
setting. Special surveillance or serial surveys may need to be established to monitor the
situation regarding falls. The majority of falls are preventable; the time for action is now.
Acknowledgements
The authors of this paper wish to acknowledge the contributions of Mrs. Desmalee Nevins-Holder, Mr. Shane Williams, Ms. Grace Stephenson, to the development and evolution of this paper.
40
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Elderly. Ann Acad Med Singapore 2005[cited 2006 September 25];34:60-72. Available from http://www.annals.edu.sg/pdf200502/ChuW.pdf#search=%22falls%20and%20elderly%20and%20China%22
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8. Reyes-Ortiz CA, Al Snih S, Markides KS. Falls among elderly persons in Latin
America and the Caribbean and among elderly Mexican-Americans. Rev Panam Salud Publica. 2005 [cited 2006 September 4];17(5/6):362–9. Available from http://www.scielosp.org/pdf/rpsp/v17n5-6/26273.pdf#search=%22falls%20in%20the%20elderly%20and%20Caribbean%22
9. Velkoff V and Lawson V. Gender and Aging: Caregiving. International Brief. 1998
December [cited 2006 September 6]; pp. 1-7. US Department of Commerce, Economics and Statistics Administration, Bureau of Census.; Available from http://www.census.gov/ipc/prod/ib-9803.pdf
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10. Melton LJ. Hip fractures: a worldwide problem today and tomorrow. Bone. 1993;14 Suppl
1:S1-8 11. Cumming RG Nevitt MC, and Cummings SR. (1997). Epidemiology of Hip Fractures.
Epidemiol Rev. 1997[cited 2006 September 15];19(2):244-257. Available from http://epirev.oxfordjournals.org/cgi/reprint/19/2/244.pdf
12. UN.org. Country profile: Status and implementation of national policies on ageing in
Jamaica. [cited 2006 September 15]. Available from http://www.un.org/esa/socdev/ageing/workshops/vn/jamaica.pdf
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Galvez-Vargas R. Risk factors in falls among the elderly according to extrinsic and intrinsic precipitating causes. European Journal of Epidemiology. 2000;16(9):849-859
17. Fuller GF. Falls in the elderly. American Family Physician. 2000 [cited 2006
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Kingston Jamaica: Ministry of Labour and Social Security; 2000.
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APPENDIX I PAHO/WHO COLLABORATING CENTRE FOR AGEING AND HEALTH
THE MONA AGEING AND WELLNESS CENTRE UNIVERSITY OF THE WEST INDIES (MONA)
DEPARTMENT OF COMMUNITY HEALTH & PSYCHIATRY
Tool for data collection on falls This tool is designed to collect data from dockets only. It is not intended to identify patients or to interface with patients or their relatives. The docket number is only collected to prevent duplication of information. The location is of public health interest only and no detail address must be taken. What is required is eg Kingston 11, Bath St Thomas study only Docket number _________________________ Address ___________________________________ Age _______________________ Gender ____________________________ Date of visit/ admission____________________ Diagnoses ______________________________ Date of discharge _________________________ Duration of hospital stay ________________________ Or Number of visits to health Centre _________________________ Co morbidity diabetes hypertension heart disease mental disorders other (state) ___________________ Disability or impairment sight hearing mobility touch smell other (state)___________ Medical History resulting in fall ______________________________________ ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ _______________________ Intervention _____________________________________________________________ ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ Outcome________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
43
____________________________________________________________________________________________________________
Other Comments _______________________________________________________________
44
APPENDIX II FOCUS GROUP DISCUSSION QUESTIONS
PERCEPTION OF RISK FOR FALLS
Thank you for accepting to come to a meeting that will be held on September 13, 2006 at 10:00 am at (location) to talk about falls in persons 60 years and older. Here are the questions you will be asked during that meeting. Please read them before coming and think about what you will want to say in answering these questions. Think about the corrective and preventative measures that can be put in place to prevent falls and how these measures can be implemented. QUESTIONS
1. How many of you have fallen recently? 2. What is it like to live in your house? 3. Do you feel afraid that you may fall? 4. In what area of the house do you think you are most likely to fall and why? 5. When you leave home what activity example (taking the bus, going into a
building, climbing the ramp etc.) do you think create the greatest risk for falling? 6. When walking on the road what are challenges that could lead to a fall? 7. When entering a building what are the challenges that could lead to falls? 8. When taking public transportation what are the risks of falling?
Fall Prevention measures
1. What are some fall prevention measures applicable to the home setting? 2. What are some of the fall prevention measures applicable to public buildings? 3. What are some of the fall prevention measures applicable to public
transportation? 4. What are some of the policies you would like to see in place to prevent falls in
senior citizens?
45
APPENDIX III: FOCUS GROUP SUMMARY MATRIX.
Places where falls occur and suggested reasons
Impact of fall Fall Prevention Strategies
On the public bus
• Not enough seats on bus so seniors stand and fall
• The steps are too high
• Not enough seats dedicated to seniors
• Not enough low rails to hold. So seniors loose balance and fall
• On the streets
• Fell in pothole
• Fell in puddle of water on street
• Fell because sidewalk is uneven
• Fell because of no sidewalk
Violence
• Attack by robbers
At home
• In Bathroom
• On rugs
• On steps
• Off ladder
• In water on floor
Loss of job and hospitalization Fractured limbs Very expensive medical bills Loss -shoe Damage- legs Lost handbag Fractures
• Bus for seniors only
• More seats on bus dedicated to seniors
• Bus crew too impatient and ill-mannered, need special crew for seniors.
• Need more respect from the public for seniors.
• Road repair and maintenance
• Fix potholes
• Make sidewalk
• Improve lightening
• Improve crossing for seniors
• Improve road surface
•
• debush the place and make more parks so less likely for robbers to hide
• Improve lighting Make home safer
• Use non slips tiles
• Remove rugs and other floor pieces out of path
• Make floor surfaces even
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